Marine Cargo Claim Form
The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to
ALLIANZ NIGERIA INSURANCE PLC
Immediate Notice Must Be Given To The Police
Insured Name:
*
Address:
E-Mail:
*
Telephone Number
*
Business of Insured
Policy No
Nature of Goods
Date Goods were delivered
Value of Consignment
What point was the loss discovered?
Circumstances for loss
Amount of Loss
Value of Salvage, if any
Value of Consignment
Condition of consignment when received:
If claim for recovery made against carrier or third parties give particulars and result (Correspondences should be attached to this form)
Is there any other insurance covering the loss?
please select
Yes
No
If so, state the nature of cover & company interested
2
Declaration
I/We further declare that the details of loss mentioned on the other side, and insured under the Marine certificate number
Dated, Under the policy of Marine Insurance with
ALLIANZ NIGERIA INSURANCE PLC was damaged or short landed to the
I/We further declare that
Witness my/our hand this
Signature
Date
Submit
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Receivers' Email